Last weekend, Democrats in California gathered to choose their new state party leader. And, is if they set out to prove that we will keep playing out the Democratic presidential primary until the endtimes, fault lines between establishment Democrats and Bernie Sanders supporters created a fissure in the convention.

At one point, Ellis-supporting protesters interrupted DNC Chair Tom Perez’s reception at the state convention. “Hey, shut the fuck up or go outside,” state party Chairman John Burton told them. “Parade all you want, but unless we put it on the ballot or elect new Democrats you can walk up and down the street and people still aren’t going to have decent healthcare. So let’s get with it.”

Those tensions came to a head this week, as the California state legislature reviewed a bill that would set up a single-payer healthcare system in the state—the first of its kind in the country.

The bill, called the Healthy California Act, would enact a Medicare-for-all system that would provide government-funded healthcare for every Californian. The only catch: The Senate appropriations committee estimated the bill would cost $400 billion per year to implement. (Existing state and local funding would cover roughly half of the costs.) Critics have predictably balked at that number, noting that it would exceed California’s entire state budget.

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One of the biggest players in the single-payer debate has been the National Nurses United union. RoseAnn Demoro, the union’s executive director, was an outspoken Bernie Sanders supporter during the Democratic presidential primary, and has now turned her focus to pushing California’s state Democratic party to the left.

“No one wants to be in the position to go too far out on a limb,” said Holly Miller, the National Director of Community and Public Advocacy of National Nurses United. “There’s heavy pushback from the pharmaceutical industry, there’s heavy pushback from the insurance industry.”

California offers a microcosm of intra-Democratic Party quarreling, and will likely continue to do so throughout the Trump/Pence administration. The argument tends to run: Should Democrats be focusing their efforts on protecting the gains made under the Obama administration, or continue to push policy farther left, despite having little real political power? And is now, while Trump and the GOP control so much, the best time to be having this conversation?

“Some people are saying it’s the worst time, and some people are saying it’s the best time,” said Deborah Kelch, the executive director of the nonpartisan Insure the Uninsured Project in California.

Californians have a lot to lose if Republicans in Congress succeed in repealing Obamacare. Under the Affordable Care Act, California saw the largest reduction in its uninsured population of any state. Before the ACA’s implementation, the state’s uninsured rate was 17 percent. By 2016, California’s uninsured rate had dropped to 7.1 percent.

Kelch says that while it’s important to be having these debates, the number one priority should be preserving the gains made under Obamacare.

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“Any conversation or policy proposal that is about getting a state to universal coverage is worth the conversation,” she said. “That said, in this particular moment, we are really facing a serious threat to what we have already done.”

Miller says that those on the left should take heart in the results of California’s state convention, even if the establishment candidate won. She noted that the Berniecrats came very close to winning, despite making up just a third of the convention’s voting body.

“The fact that we came within 62 votes of taking over the party with the base is miraculous,” she said. “Frankly it’s just a matter of time.”

The battle for single-payer in California, and the debate over its costs, are of vital importance to people who hope to take the campaign for universal healthcare national. Any truly universal national program will come with a similarly large sticker price. But the way we define “healthcare costs” tends to specify only what the government directly spends, and not the total costs borne by the country as a whole. Single-payer critics argue that levying more taxes to achieve full health coverage is too costly, though they accept that America already spends a truly massive amount of money for less-than-adequate care.

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The United States already spends more than any other country on healthcare—17.1 percent of its GDP, according to the World Health Organization—for less coverage. In contrast, Canada spends 10.4 percent of its GDP on healthcare, and the United Kingdom spends just 9.1 percent of its GDP on healthcare. Both nations have truly universal systems.

Republicans, for all their talk of fiscal responsibility, seem intent on keeping the American healthcare system just as costly while eroding care for the sick, the poor, the elderly, the unemployed and the disabled. The AHCA would drastically cut Medicaid funding nationwide, despite President Trump’s promise during the campaign that he wouldn’t cut Medicare or Medicaid funding. The president’s budget would actually go farther than the AHCA in cutting federal funding for health insurance for low-income Americans. It would cut Medicaid by more than$1.4 trillion over the next ten years, decimating the American safety net.

This is monstrous policy. It is also a huge opportunity for those advocating for a fairer society. American voters aren’t happy with the healthcare plan the Republican party is offering. A recent Quinnipiac University poll found that just 20 percent of Americans approve of the GOP’s health care bill. When you consider how precarious access to care is for so many Americans, and how much the Trump administration and Republicans in Congress plan to gut what access there is, a universal program sounds even more appealing. When you consider what we already spend on healthcare, for such suboptimal outcomes, the idea of $400 billion in a full-coverage system in California starts to sound less crazy.

The vast majority of people would come out financially ahead under even an absurdly generous single-payer system. Perhaps more important, truly guaranteed health care would mean relief from the constant nagging worry that job loss, or a change in coverage plan, or a sudden emergency landing you in an out-of-network hospital would lead to untreated illness or financial ruin. No more would illness mean taking up a second job trying to navigate the brain-melting complexity of a monstrous, wasteful billing system. Medicare-for-all would be a relief on so many levels that many Americans simply can’t conceive of it. But if it were to pass, it would be immediately popular — and forevermore politically untouchable.

Of course, even if they are able to agree on the single-payer question, Republicans in power at the federal level presents huge structural barriers to Democratic states like California. Regardless of whether single-payer in California is a good idea or even an achievable one, the work must continue at the national level.

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The good news is, within the Democratic Party, support for single-payer appears to be building. Michigan Rep. John Conyers, currently the longest-serving member of Congress, has introduced a Medicare For All bill during every legislative sessions since 2003. In the 2015-2016 session, Conyers’ Medicare For All bill drew 62 Democratic cosponsors. This year, that number doubled to 112 Democratic cosponsors—representing more than half of the House Democratic caucus.

Healthcare is not going away as a political issue anytime soon. Democrats and those on the left have to decide: Will they remain hemmed in by conservative definitions of what qualifies as adequate care, and how much we as a society ought to spend on it? Or do we dare to dream a little bigger?